Vulvovaginal atrophy, also referred to as vaginal atrophy, urogenital atrophy, or atrophic vaginitis, results from estrogen loss and is associated with vulvovaginal complaints like dryness, burning, and painful intercourse in menopausal women. Urinary complaints are not uncommon, including frequency and recurrent bladder infections, which is why a newer term “genitourinary syndrome of menopause” or GSM was introduced a few years ago.
The hallmark symptoms of vulvovaginal atrophy include lack of vaginal lubrication and pain with intercourse. Up to 45% of women around the time of and after menopause will suffer from these issues, but few will seek help or treatment from their gynecologist. Hot flashes associated with menopause tend to improve over time, but vulvovaginal atrophy typically does not. It has the potential to negatively impact a woman’s sexual health and quality of life beyond the time classically thought of as menopause. Menopause is not a finite event – not like flipping a switch – but a transition in a woman’s life.
Symptoms women often report include dryness, irritation of the outside of the vagina (vulva), burning or pain with urination, and pain with sexual intercourse (dyspareunia). Pain from vulvovaginal atrophy can lead to decreased interest and eventually avoidance of sex. It is not uncommon that women report bleeding with intercourse or with wiping, due to the thin and brittle vaginal tissue. Left untreated, the vaginal tissue can become ulcerated, tear, or narrow (stenosis) – further leading to pain with sex. Estrogen receptors are present in the vaginal tissue, so low estrogen states, most commonly natural menopause, are most likely the culprit of this condition.
When women report symptoms or upon routine enquiry of possible unreported conditions at an annual well woman exam suggests vulvovaginal atrophy, additional detail is sought and a pelvic exam performed to evaluate the possible causes. Other possible causes of these symptoms may include infection, irritation from soaps, liners, or clothing, or even another condition entirely like lichen sclerosis. These need to be excluded before treatment. Some conditions which present similar to vulvovaginal atrophy may require a biopsy of the vaginal or vulvar tissue. Once the diagnosis of vulvovaginal atrophy is confirmed, the goal of treatment is relief of symptoms. Options to alleviate symptoms of atrophy include nonhormonal lubricants and hormonal vaginal estrogen.
There are several lubricants available on the market, including water, silicone, and oil-based products. Some women find coconut and olive oil therapeutic. There is little information in medical journals to report the effectiveness and safety of these products, but many women report favorable results with their use. Some lubricants may cause irritation, especially on thin (atrophied) tissues. We recommend that patients test products on a small patch of skin for 24 hours before using intravaginally. Not all products are appropriate for use with condoms as they can erode the material (especially latex), creating an ineffective barrier for contraception or prevention of sexually transmitted infections.
Vaginal estrogen is the preferred option when a patient’s symptoms are restricted to the vagina. Several medical studies confirm the effectiveness of vaginal estrogen; showing decreased vaginal dryness, decreased pain with intercourse, and decreased urinary tract infections (UTIs). Other evidence of the treatment effectiveness is observed on pelvic exams with thickening of the vaginal tissue and visibly less irritation of the tissue.
Vaginal estrogen is safe in well-selected women without risk factors. The estrogen levels measured in labs collected from women treated with vaginal estrogen are below the average level for postmenopausal women. This shows that the medication is having its effects locally and very little is absorbed through the rest of the body. Because of this limited systemic (whole body) absorption, a progestin is generally not required for women using low-dose vaginal estrogen. The North American Menopause Society (NAMS) advises avoiding sexual activity for at least 12 hours after using vaginal estrogen to avoid absorption by your sexual partner.
There are other treatment options beyond vaginal estrogen or lubricants for vulvovaginal atrophy, including other topical creams, oral pills, and vaginal lasers (e.g. MonaLisa Touch ®). If you have symptoms, please know there are treatments available and reach out to our office for evaluation.
Dr. Kaleb Jacobs